VSMMC

Pediatrics
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Objectives

To know Dengue as to:

• Etiology
• Epidemiology
• Pathophysiology
• Classification
• Clinical Presentation
• Diagnosis
• Management
• Prevention

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PRETEST
1. Dengue Virus is a single stranded RNA which belongs to what
family of virus?
a. Flaviviridae
b. Filoviridae
c. Hepeviridae
d. Parvoviridae

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PRETEST
2. How many serotypes dengue virus have?

3. Enumerate each type

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DISCOVERY OF 5TH SEROTYPE
• The 5th variant DENV-5 has been isolated in October 2013
• This serotype follows the sylvatic cycle unlike the other 4 serotypes
which follow the other four serotypes which follow the human cycle
• Likely cause of emergence of the new serotype could be genetic
recombination, natural selection, and genetic bottlenecks

SYLVATIC - transmitted to non-human primates

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PRETEST
4. Dengue is transmitted by what type of mosquito?

5 - 8. Give at least 4 warning signs of dengue

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PRETEST
Trishia Madonna is a px admitted at ward 10, when you ORAS IHI
made rounds she give you the list of her urine collected
for the past 8 hours. Her weight is 30kg. 6am 300
9) What is her Urine Output 7am 180

10) Is it adequate?? 8am 90

9am 100
11 – 13) What are the 3 phases of dengue fever 10am 100

14 – 15) Give at least 2 complications of dengue 11am 130

12pm 90
1pm 70

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Case Sample 1
A 3yo female came at ER with complaints of
4days fever, epistaxis, vomiting and
abdominal pain.
PE: BP 80/50 RR 22cpm HR 110 Temp 38.7 px is
flushed with strong pulses and CRT of <2sec
Outside labs revealed
WBC 2.1 hct 47 hb 135 N 38% L 62% plt 50
A. Maintain IVF at same rate
B. Increase D5NSS at 7cc/kg/hr
C. Shift IVF to PNSS then regulate at
7cc/kg/hr
D. Shift IVF to PNSS then regulate at
5cc/kg/hr

Px was admitted by your resident as Dengue

Fever with warning signs. Started with IVF
with D5NSS 1L at 5cc/kg/hr and was
transported at Ward 10. Upon reassessment
vitals were BP 90/60 RR 20cpm HR 118
Temp 38.9 UO of 0.4cc/kg/hr. What will
be your fluid rate?
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 HISTORICAL
BACKGROUND
As early as 992, a dengue-like outbreak in humans
was recorded in a Chinese medical encyclopedia

In 1771, Dr. Jose Sabater, a physician at the

military hospital in San Juan, Puerto Rico,
recommended treating dengue with small
quantities of rum. At the time, the disease was
called "break-bone fever." 
In 1943, Ren Kimura and Susumu Hotta first
isolated the dengue virus. These two scientists
were studying blood samples of patients taken
during the 1943 dengue epidemic in Nagasaki,
Japan. 
The first epidemic of severe dengue was reported
in Manila, Philippines, in 1953, and the disease
continued to spread in Southeast Asia during the
next 20 years. 
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 Dengue Virus
• Genus Flavivirus, within the family Flaviviridae.
• Flaviviruses are lipid-enveloped, positive-sense,
single-stranded RNA viruses
• 4 dengue virus serotypes (DEN-1, DEN-2, DEN-3
and DEN-4)
• Arthropod-transmitted

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Vector

Aedes aegypti Aedes

albopictus
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 Epidemiology

Dengue is the most rapidly spreading

mosquito-borne viral disease in the world

An estimated 50 million dengue infections

occur annually and approximately 2.5 billion
people live in dengue endemic countries

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Regions that exceeded the epidemic
threshold:
• Mimaropa
• Western Visayas
• Central Visayas
• Northern Mindanao

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Regions that exceeded the alert
threshold:
 Ilocos Region  Davao
 Cagayan Valley  Bangsamoro
 Calabarzon Autonomous Region
 Bicol in Muslim Mindanao
 Eastern Visayas  Cordillera
 Zamboanga Administrative
Peninsula Region.

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Health Secretary Francisco Duque
III said 106,630 dengue cases
had been reported from January
1 to June 29, 2019 – 85% more
than the 57,564 cases reported
from the same period in 2018.

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DENGUE VIRUS

1970’s

2004

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PATHOPHYSIOLOGY

increased capillary
fragility
Strong immune- Produce
complex reaction substances like
similar to histamines,
anaphylactoid serotonins,
reactions bradykinins
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY

thrombocytopenia
acute excessive
faulty maturation of
consumption of platelets
megakaryocytes-
due to generalized
resulting in diminished
intravascular clotting
production
similar to DIC
PATHOPHYSIOLOGY

decreased blood
coagulation factors
Fibrinogen Prolonged
and factors CT-BT, PT,
II, V, VII, IX PTT
PATHOPHYSIOLOGY

Individual risk factors determine the

severity of disease:
• secondary infection
• Age
• Ethnicity
• possibly chronic diseases (bronchial asthma, sickle
cell anemia and diabetes mellitus).
PATHOPHYSIOLOGY

Young children in particular may

be less able than adults to
compensate for capillary leakage
and are consequently at greater
risk of dengue shock.
Classification

Dengue Fever with Warning Signs

Dengue Severe

• Severe Plasma Leakage

• Severe Bleeding
• Severe Organ Impairment

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Phases of Dengue

Febrile

Critical

Recovery
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Clinical Problems in Each Phase
Febrile Phase
• Dehydration; high fever may cause neurological
disturbances and febrile seizures in young children

Critical Phase
• Shock from plasma leakage; severe haemorrhage;
organ impairment

Recovery Phase
• Hypervolaemia (only if intravenous fluid therapy has
been excessive and/or has extended into this period)
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 Plasma leakage
shock (dengue
shock) and/or fluid
accumulation, with
or without
respiratory distress

Dengue
Shock

Severe organ
Severe bleeding
impairment

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 Signs of Shock (Pediatrics)

Narrow pulse pressure ( 20mmHg)

Poor capillary perfusion

Rapid pulse
Cold extremities Delayed CRT
pressure

Hypotension

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 There is evidence of plasma leakage,
Severe Dengue such as:
• High or progressively rising haematocrit;
• Pleural effusions or ascites;
There is significant bleeding.
• Circulatory compromise or shock (tachycardia, cold
Endemic and clammy extremities, capillary refill time greater
area than three seconds, weak or undetectable pulse,
narrow pulse pressure or, in late shock,
unrecordable blood pressure).
2-7 days of
Fever
There is an altered level of There is severe gastrointestinal
consciousness (lethargy or involvement (persistent vomiting,
restlessness, coma, increasing or intense abdominal
convulsions). pain, jaundice).

There is severe organ impairment (acute liver

failure, acute renal failure, encephalopathy or
encephalitis, or other unusual manifestations,
cardiomyopathy) or other unusual manifestations.
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Stepwise Approach To The Management of
Dengue

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Group • Patients who may be sent home
A
Group • Patients who should be referred
for in-hospital management
B
• Patients who require
Group emergency treatment and
urgent referral when they have
C severe dengue

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 Severe bleeding

Blood Transfusion (5–10ml/kg of fresh-packed

red cells or 10–20 ml/kg of fresh whole blood);
transfuse again if indicated.
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 Complications

Fluid Overload

Hypoglycemia or hyperglycemia

Electrolytes imbalance
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Admission Criteria

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Fluids

CRYSTALLOIDS

0.9% saline (“normal” saline)

Ringer’s lactate

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Fluids

COLLOIDS

dextran-based

hydroxyethyl starch

gelatin-based
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 Fluids
Crystalloid Colloid

Gelatin Albumin HES®

Molecular weight: 60 da 30 - 35 kda 69 kda 130 kda

Volume effect: 10 - 20 mins 1 - 2 hrs 2 – 4 hrs 100% 4 - 6 hrs

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Prevention
Vector Control
Environmental Management

Chemical Management

Biological Control
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 Case Samples
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Case Sample 1
Missy Jackson, 15 year old, female, came at ER with complaints of 4
days fever, and abdominal pain.
PE: BP 100/60 RR 22cpm HR 110 Temp 38.7 strong pulses and CRT of
<2secDischarge the patient; come back with repeat CBC, Increase oral fluids
Outside labs revealed
WBC 6.1 hct 37 hb 16.5 N 50% L 42% plt 199
DX: Probable Dengue

MGT:
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Case Sample 3
April Jay, 9 year old female came at ER, very weak and pale with
complaints of 6 days fever, body malaise, abdominal pain.
PE: BP 70 palpatory RR 28cpm HR 142 Temp 36.7 px is pale with weak
pulses and CRT of 4sec
Outside labs revealed
WBC 2.1 hct 52 hb 135 N 30% L 70% plt 33
DX: Dengue Severe in Hypotensive Shock
MGT:
Give 20cc IV Bolus over 15-20 minutes; reassess then decrease
fluids accordingly
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Case Sample 2
Adrian John, 5 year old, male, came at ER with complaints of 4 days
fever, epistaxis, vomiting and abdominal pain.
PE: BP 80/50 RR 22cpm HR 110 Temp 38.7 px is flushed with strong
pulses and CRT of Start
Admit; <2sec PNSS @ 5cc/kg; Labs; PCM if needed
Outside labs revealed
WBC 2.1 hct 47 hb 135 N 38% L 62% plt 50
DX: Dengue Fever with Warning Signs

MGT:
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